Implementation of a novel digital ultrasound education tool into an emergency medicine rotation: UltrasoundBox.

Objective: We investigated the educational value of implementing a web-based e-learning program into a medical student emergency medicine rotation. We created "UltrasoundBox," a browser-based application where students interpret ultrasound (US) images. Our goal was to assess how this form of e-learning performs when compared to more passive, lecture-based online US education. We also assessed the how the students interpreted the addition this learning modality to the rotation. Methods: This is a randomized, controlled study to assess the educational outcomes of implementing UltrasoundBox compared to lecture-based US education. Fourth-year medical students on their emergency medicine rotation were enrolled in the study. Students randomized to the control arm were instructed to watch widely available educational lecture videos. Students randomized to the intervention arm received access to UltrasoundBox and were instructed to complete the clinical modules. Both groups completed the same standardized US examination before and after the trial. All the trial participants were given a survey to complete after the trial. Results: We enrolled 42 students, with 23 in the control group and 19 in the intervention group. On the post-intervention examination, the control and intervention groups were found to have mean examination scores of 61.6% and 73.6% respectively, with a statistically significant difference of 12% (95% confidence interval 1.611 to 5.56; p < 0.0005). A total of 92% of survey respondents in the intervention group indicated that UltrasoundBox was an effective tool in meeting the intended learning objectives, while only 36.8% of the control group indicated this for the online lectures (p < 0.005). Conclusions: We found that medical students using the web-based e-learning platform UltrasoundBox achieved better scores on the examination when compared to the medical students using existing online lecture-based US educational resources. The students reported that the addition of UltrasoundBox added educational value to the rotation.

Does Orally-Administered Radiocontrast Impair Ultrasound Image Quality in Pediatric Patients?

INTRODUCTION: It is commonly assumed that orally-administered radiocontrast material (ORC) preceding abdominal ultrasound (US) performance can obscure image quality and potentially impair diagnostic accuracy when assessing patients with abdominal pain. Due to this concern, ORC administration per protocol for computed tomography (CT) is often delayed until after US performance, potentially contributing to prolonged length of stay in the emergency department (ED) in patients with concern for abdominal pathology. The objective of this study was to evaluate whether early administration of ORC in children with abdominal pain receiving abdominal CT for possible appendicitis obscures subsequent abdominal US image quality. METHODS: We designed a prospective observational study of children <18 years of age presenting to a pediatric ED with abdominal pain who were set to receive ORC prior to obtaining an abdominal CT. These patients received a point-of-care ultrasound (POCUS) of the abdomen to assess the abdominal aorta and right lower quadrant (RLQ) structures (psoas muscle and iliac vessels) pre- and post-ORC administration. Images were compared independently by two blinded emergency US-certified physician-assessors for quality, specifically to determine whether ORC obscured the anatomical structures in question. RESULTS: A total of 17 subjects were enrolled, and each subject had two POCUS studies of the abdomen, one pre- and one post-ORC administration looking to visualize the anatomy of the RLQ and abdominal aorta in both studies. Statistical analysis showed no significant differences in mean values of POCUS image quality scoring by two blinded US-trained physician-assessors for either RLQ structures or abdominal aorta when performed pre- and post-administration of ORC. CONCLUSION: Early ORC administration in children with abdominal pain does not adversely affect image quality of a subsequently performed abdominal US. Patients who may require abdominal CT to determine the etiology of abdominal pain can receive early administration of ORC prior to US performance to help minimize ED length of stay without impairing US diagnostic accuracy.

Serratus Anterior Plane Block in the Emergency Department: A Case Series.

This is a case series of six emergency department (ED) patients who received an ultrasound-guided serratus anterior plane block (SAPB) for a variety of painful conditions. Our cases illustrate the feasibility and analgesic efficacy of the SAPB in providing pain management in ED patients with a variety of painful syndromes, including those with severe pain from multiple rib fractures, herpes zoster, and tube thoracostomy placement. In addition, we found no adverse events in our case series.

Association of ultrasound-related interruption during cardiopulmonary resuscitation with adult cardiac arrest outcomes: A video-reviewed retrospective study.

OBJECTIVES: To determine the association of focused transthoracic echocardiography (ECHO) related interruption during cardiopulmonary resuscitation (CPR) with patient outcomes in the Emergency Department (ED). METHODS: This was a retrospective, single center, cohort study, conducted in an urban community teaching ED. Eligible study subjects were adult patients in the ED with sustained cardiac arrest. Exclusion criteria include traumatic cardiac arrest and age less than 18. All resuscitations were video recorded and were subsequently reviewed by 2 study investigators. The no-flow time from chest compression interruption was analyzed using video review and separated into ECHO-related and non-ECHO related. Our primary outcome was patient survival to hospital discharge and the secondary outcome was the rate of return of spontaneous circulation (ROSC). Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes. RESULTS: From January 2016 to May 2017, a total of 210 patients were included for final analysis. The median total no-flow time observed on video was 99.5 s (IQR: 54.0-160.0 s). Among these, a median of 26.5 s (IQR: 0.0-59.0 s) was ECHO-related and a median of 60.5 s (IQR: 34.0-101.9) was non-ECHO-related. The ECHO-related no-flow time between 77 and 122 s (OR: 7.31, 95 % confidence interval [CI]: 1.59-33.59; p-value = 0.01) and ECHO-related interruption ≦ 2 times (OR: 8.22, 95% CI: 1.51-44.64; p-value = 0.01) were positively associated with survival to hospital discharge. ECHO-related interruption ≦ 2 times (OR: 5.55, 95% CI: 2.44-12.61; p-value < 0.001) was also positively associated with ROSC. CONCLUSION: Short ECHO-related interruption during CPR was positively associated with ROSC and survival to hospital discharge. While ECHO can be a valuable diagnostic tool during CPR, the no-flow time associated with ECHO should be minimized.

Interscalene brachial plexus nerve block in the emergency department: an effective and practice-changing workshop.

BACKGROUND: The interscalene brachial plexus nerve block (ISNB) is a potentially useful method of regional analgesia for humerus fracture and shoulder dislocation reduction in the Emergency Department (ED). We examined the effectiveness of an ISNB workshop given to emergency medicine (EM) residents. We also explored complication rates and effectiveness of ISNBs performed in the ED. METHODS: One-hour evidence-based ISNB workshops were conducted with EM residents. Participants were given pre-, post-, and 3-month post-workshop knowledge and technical assessments. Results were analyzed using descriptive statistics. A pre- and post-workshop chart review examined ISNB utilization, complications, post-ISNB opiate administration, and post-ISNB procedural sedation. RESULTS: 41 residents enrolled in the workshop. Pre-workshop pass rate: knowledge assessment 22%. Immediate post-workshop pass rates: knowledge assessment 100%, image acquisition 93%, needle placement 100%. Three months post-workshop pass rates: knowledge assessment 73%, image acquisition 76%, needle placement 100%. Areas of poorest knowledge retention were anatomical landmarks, block distribution, and early signs of LAST. In the chart review, 2 ISNBs were performed in the pre-workshop period, and 12 in the post-workshop period. No serious complications were recorded. 78.5% of attempted ISNBs were successful, without need for procedural sedation. Of the 11 successfully performed ISNBs, 91% received no opiates after the procedure. CONCLUSIONS: Our study suggests that EM residents can learn the ISNB, perform it safely in the emergency department, and that the ISNB may be an alternative to procedural sedation and opiate use for shoulder dislocation. Residents are adept at ISNB technical skills but demonstrate some deficits in knowledge retention.

Ultrasound-guided regional anesthesia simulation: use of meat glue in inexpensive and realistic nerve block models.

BACKGROUND: Ultrasound-guided regional anesthesia (UGRA) is increasingly used by emergency physicians to provide safe and effective pain relief for patients. However, one of the factors limiting its widespread use is the lack of realistic models available for learners to train on. There are currently no inexpensive nerve block models available that are injectable and that closely mimic nerves, fascial planes, muscles, and other landmarks. Our aim is to create inexpensive, injectable nerve block models that can be used as effective medical training tools for UGRA. METHODS: By using a lean cut of pork such as pork loin, yarn soaked in ultrasound gel to simulate peripheral nerves, and drinking straws filled with gel to represent vascular structures, we created various nerve block models. Meat glue applied between sections of meat appears hyperechoic under ultrasound, thereby mimicking fascial planes and has the added benefit of helping to secure the components of the model together. Using these elements, we were able to create realistic peripheral nerve, fascia iliaca compartment, serratus anterior plane, and interscalene brachial plexus models. RESULTS: One of the necessary skills in performing UGRA involves placing the needle tip along a fascial plane and visualizing hydrodissection of this plane with the local anesthetic. When meat glue (transglutaminase) is applied between layers of meat such as pork loin, the meat binds together and creates a hyperechoic line that mimics a fascial plane. When meat glue is applied to two apposing fascial layers naturally occurring on the meat, the fascial plane can be injected, and fluid can be seen hydrodissecting in this space. We created several nerve block models using meat glue and other components to mimic normal landmarks. CONCLUSIONS: We have developed inexpensive and easily reproducible models that create the realistic appearance of tissues, nerves, and fascial planes under ultrasound. They can also accurately simulate hydrodissection of fluid in fascial planes. We hope these nerve block models will allow for the education in UGRA to be more widespread and accessible to learners from all specialties.

Does oral radiocontrast affect image quality of abdominal sonography?

OBJECTIVE: Emergency Department patients with abdominal pain may require both an ultrasound (US) and computed tomography (CT) for an accurate diagnosis. Patients are often asked to drink oral radiocontrast while awaiting ultrasound, in order to better expedite a CT in the case of a non-diagnostic US. The impact of oral radiocontrast on US image quality has not been studied. We compared the quality of US images obtained before and after the ingestion of oral radiocontrast in healthy adult volunteers. METHODS: This was a prospective study in which adult volunteer subjects underwent sonographic studies of the aorta, the right upper quadrant, the right lower quadrant, and the Focused Assessment with Sonography in Trauma (FAST) examination. Initial studies were performed prior to ingestion of oral radiocontrast, with subsequent imaging occurring at 1 and 2hour post-ingestion. All of the images from the sonographic exams were randomized and subsequently scored for quality by two emergency ultrasound fellowship trained emergency physicians with extensive experience in performing and interpreting US. RESULTS: 638 images from 240 exams were obtained from 20 subjects at three time points. Six exams were not scored due to inadequate images. There were no significant differences in image quality for any of the US exam types after the ingestion of oral radiocontrast at 1 and 2h. CONCLUSION: Ingestion of oral radiocontrast did not affect image quality of four common abdominal ultrasound examinations.

When Fever, Leukocytosis, and Right Lower Quadrant Pain Is Not Appendicitis.

Mesenteric cystic lymphangioma (MCL) is an uncommon, benign, slow-growing abdominal tumor that is derived from the lymphatic vessels (World J Gastroenterol. 2012;18:6328-6332, Radiographics. 1994;14:729-737). It is most often diagnosed in the head and neck of affected children. Rarely, a lymphangioma can develop within the small bowel (Pan Afr Med J. 2012;12:7). The clinical presentation of patients with an abdominal MCL can range from asymptomatic to acute abdominal pain (J Korean Surg Soc. 2012;83:102-106). We report a case of small bowel volvulus caused by an MCL in a 3-year-old child who presented to the pediatric emergency department with right lower quadrant pain. The child was thought to have a perforated appendicitis and was taken to the operating room where an MCL was identified and resected. This case illustrates the need to consider MCL when a patient presents to the emergency department with right lower quadrant pain.

Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion.

OBJECTIVES: Dyspnea is a common emergency department (ED) condition, which may be caused by pleural effusion and other thoracic diseases. We present data on a new sonographic marker, the extension of the thoracic spine sign, for diagnosis of pleural effusion. METHODS: In this prospective study, we enrolled a convenience sample of undifferentiated patients who underwent computed tomography (CT) of the abdomen or chest, which was performed as part of their emergency department evaluations. Patients underwent chest sonography to assess the utility of the extension of the thoracic spine sign for diagnosing pleural effusion. The point-of-care sonographic examinations were performed and interpreted by emergency physicians who were blinded to information in the medical records. Sonographic results were compared to radiologists' interpretations of the CT results, which were considered the criterion standard. RESULTS: Forty-one patients were enrolled, accounting for 82 hemithoraces. Seven hemithoraces were excluded from the analysis due to various limitations, leaving 75 hemithoraces for the final analysis. The median time for completion of the sonographic examination was 3 minutes. The sensitivity and specificity for extension of the thoracic spine were 73.7% (95% confidence interval [CI], 48.6%-89.9%) and 92.9% (95%CI, 81.9%-97.7%), respectively. Overall, there were 5 hemithoraces with false-negative results when using the extension sign. Of those 5 cases, 4 were found to have trace pleural effusions on CT. When trace pleural effusions were excluded in a subgroup analysis, the sensitivity and specificity of extension of the thoracic spine were 92.9% (95% CI, 64.2%-99.6%) and 92.9% (95% CI, 81.9%-97.7%). CONCLUSIONS: We found the extension of the thoracic spine sign to be an excellent diagnostic tool for clinically relevant pleural effusion.

Point-of-care ultrasound detection of acute scaphoid fracture.

In cases of traumatic wrist pain, emergency physicians must maintain a high index of suspicion for scaphoid fractures due to their potential for serious complications. A growing body of literature supports the use of point-of-care ultrasonography by emergency physicians in the evaluation of potential fractures. We report a case of a pediatric scaphoid fracture that was initially not visualized on x-ray and was subsequently detected using point-of-care ultrasound in the ED.

Inflating the endotracheal tube cuff with saline to confirm correct depth using bedside ultrasonography.

Although bedside ultrasonography can accurately distinguish esophageal from tracheal intubation, it is not used to establish the correct depth of endotracheal tube insertion. As indirect sonographic markers of endotracheal tube insertion depth have proven unreliable, a method for visual verification of correct tube depth would be ideal. We describe the use of saline to inflate the endotracheal cuff to confirm correct endotracheal tube depth (at the level of the suprasternal notch) by bedside ultrasonography during resuscitation. This rapid technique holds promise during emergency intubation.

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children.

OBJECTIVE: We evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth. METHODS: We performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth. RESULTS: Forty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90-100%), a specificity of 96.4% (95% CI=87-100%), a PPV of 96.5% (95% CI=87-100%), a NPV of 98.8% (95% CI=89-100%), a positive likelihood ratio of 32 (95% CI=6-185), and a negative likelihood ratio of 0.015 (95% CI=0.004-0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0-15.0s). CONCLUSIONS: Sonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.

Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department.

BACKGROUND: Hip fracture (HFx) is a painful injury that is commonly seen in the emergency department (ED). Patients who experience pain from HFx are often treated with intravenous opiates, which may cause deleterious side effects, particularly in elderly patients. An alternative to systemic opioid analgesia involves peripheral nerve blockade. This approach may be ideally suited for the ED environment, where one injection could control pain for many hours. OBJECTIVES: We hypothesized that an ultrasound-guided fascia iliaca compartment block (UFIB) would provide analgesia for patients presenting to the ED with pain from HFx and that this procedure could be performed safely by emergency physicians (EP) after a brief training. METHODS: In this prospective, observational, feasibility study, a convenience sample of 20 cognitively intact patients with isolated HFx had a UFIB performed. Numerical pain scores, vital signs, and side effects were recorded before and after administration of the UFIB at pre-determined time points for 8h. RESULTS: All patients reported decreased pain after the nerve block, with a 76% reduction in mean pain score at 120 min. There were no procedural complications. CONCLUSION: In this small group of ED patients, UFIB provided excellent analgesia without complications and may be a useful adjunct to systemic pain control for HFx.

Substituting whole blood for urine in a bedside pregnancy test.

BACKGROUND: Point-of-care testing for rapid detection of pregnancy in women of reproductive age is common practice in the emergency department. Commercially available rapid human chorionic gonadotropin (hCG) immunoassays are validated for use with urine and serum, but not whole blood. STUDY OBJECTIVES: We assessed the validity of using whole blood to detect pregnancy using a point-of-care hCG assay by comparing it to a laboratory quantitative serum hCG assay as the criterion standard. METHODS: A convenience sample of female patients of reproductive age (18-51 years) submitted 5mL of whole blood, from which two drops were immediately applied to a point-of-care hCG kit, with results recorded at 10min. The remainder of each whole blood specimen was sent to the hospital laboratory for the criterion-standard quantitative serum hCG assay. The criterion standard for a positive pregnancy test was defined as quantitative serum hCG≥5 mIU/mL. Investigators performing the whole blood test and laboratory technicians performing the quantitative serum assay were blinded to one another's results. RESULTS: There were 633 patients enrolled, with a mean age of 30 years (± 7.7 years); 34% of the patients were pregnant. Overall, the whole blood pregnancy test was 95.8% sensitive (negative predictive value 97.9%), whereas the urine test was 95.3% sensitive (negative predictive value 97.6%); the specificity and positive predictive value of both tests was 100%. CONCLUSION: Using a standard point-of-care qualitative hCG immunoassay kit, whole blood may be used for rapid detection of pregnancy with similar, or greater, accuracy than urine.